Based on interview and record review the facility failed to ensure pain management was provided for one resident, (Resident #1) when staff failed to obtain any medications for the resident for the first 48 hrs after admission from an acute hospital stay following a vehicle accident. The facility census was 39. Review of facility policy, protocol for pain management and as needed medication, undated, showed: -Pain management must be provided to a resident who requires such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences; -Nurses will complete a pain evaluation on each resident for pain upon admission to the facility every week for four weeks, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. -The nurses will either use the FACES pain rating scale (for non-verbal or cognitively impaired residents or residents that do not speak English) or the 10 point pain intensity scale. -Nursing staff and physician will identify the nature and severity of pain. -The physician will order appropriate non-pharmacologic and medication interventions to address the resident's pain. -With input from the resident or resident representative, the physician and staff will establish goals of pain treatment. The resident's care plan will include the resident's goals, desired outcomes, and preferences. -The nursing staff will monitor for adverse effects of pain medications and report to physician. -PRN (as needed) pain medication may be ordered for occasional or break through pain. -Document PRN pain medication in Medication administration record and narcotic control record if applies. -Document results of the follow up pain assessment. -Nurses will notify the supervisor if the resident refused the medication. 1. Review of Resident #1's admission minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 11/1/24, showed: -He/She was cognitively intact; -He/She had clear speech, was able to make self-understood and had clear comprehension of others; -His/Her pain frequency was frequent with a numeric rating of 8 on a one to ten scale; -He/She had recent orthopedic surgery requiring long term care from repair fractures; -He/She was dependent on walker and wheelchair; -He/She required substantial/maximal assistance with all transfers -Diagnoses included displaced fracture of body of left talus (bone in foot that connects the ankle to the leg), fractures and other multiple trauma, fracture of the shaft of the left fibula, ocular laceration and rupture with prolapse or loss of intraocular tissue, laceration without a foreign body of part of the head, laceration without a foreign body unspecified lower leg, chronic obstructive pulmonary disease, I48.20-chronic atrial fibrillation that is unspecified, generalized anxiety disorder. Review of care plan, dated 11/1/24, showed: -Resident had acute and chronic pain due to physical disability, chronic obstructive pulmonary disease (COPD), chronic pain, fracture of left leg, foot and ankle, and medical procedure open reduction and internal fixation (ORIF) (a surgical procedure that treats broken bones or dislocations by realigning the bones and stabilizing them with internal hardware) of left ankle and leg fracture. -Resident's pain is aggravated by movement and letting the leg be dependent; -Resident's pain was alleviated/relieved by specifically oxycodone at current time; -Administer analgesia oxycodone as per orders. Give half hour before treatments or care; -Identify, record, and treat resident's existing condition which may increase pain and/or any discomfort: arthritis, neuropathy, COPD, and limited ability to move due to swelling of ankles. -Monitor, record, report to nurse resident complaints of pain or requests for pain treatment. Review of physician's order recap, dated 10/24/24-11/7/24, showed: -Ordered 10/25/24, pain scale twice daily every day and evening shift for pain assessment pain level 0-10, started 10/28/24; -Ordered 10/26/24, Acetaminophen oral tablet 500 milligrams (mg), give 2 tablet orally every 8 hours for pain, start date 10/26/24; -Ordered 10/26/24, Alprazolam oral tablet .25 mg, give 1 tablet by mouth every four hours as needed for anxiety, start dated 10/26/24, discontinued 10/27/24; -Ordered 10/26/24, Gabapentin capsule 300 mg, give 1 capsule by mouth three times a day for neuropathy, started 10/26/24; -Ordered 10/26/24, Methocarbamol oral tablet 750 mg, give 1 tablet by mouth four times a day for muscle spasm, started 10/26/24; -Ordered 10/26/24, Oxycodone hcl oral capsule 5 mg, give 1 capsule by mouth every 4 hours as needed for pain, started 10/26/24, discontinued 10/27/24 -Ordered 10/27/24, Alpraxolarm oral tablet 25 mg, give 1 tablet by mouth every 8 hours as needed three times a day in the morning, at noon, and bedtime for anxiety; -Ordered 10/27/24, Oxycodone hcl oral tablet 5 mg, Give 1 tablet by mouth ever 4 hours as needed for severe pain (8-10) for up to 3 days until 10/30/24, started 10/27/24; discontinued 10/30/24. -Ordered 11/1/24, Oxycodone hcl oral tablet 5 mg, give 5 mg by mouth every 4 hours as needed for severe pain. During an interview on 11/7/24 at 11:24 A.M., Resident #1 said: -When he/she first admitted to the facility he/she did not have his/her medications at all for two days; -Not having his/her medications made him/her feel terrible as he/she hurt all over; -His/Her pain level increased due to not having his/her medication and he/she felt miserable; -He/She had high anxiety due to not knowing when he/she would receive his/her pain relief; -He/She had a very rough few days upon admission; -He/She wouldn't want anyone to have to go without their medications like he/she did. Review of Medication Administration Record, dated October 2024, showed: -Pain Scale BID, every day and evening shift for pain assessment pain level 0-10, showed: -10/28/24 -Evening shift had first entry;-Started 10/26/24, Acetaminophen oral tablet 500 mg, give 2 tablet orally every 8 hours for pain, -10/26/24 showed: -12:00 A.M. had an x; -8:00 A.M. had no entry and was blank; -4:00 P.M. had no entry and was blank; -10/27/24 showed: -12:00 A.M. had no entry and was blank; -8:00 A.M. medication was administered; -Started 10/26/24, Gabapentin capsule 300 mg, give 1 capsule by mouth three times a day for neuropathy: -10/27/24 showed: -Morning had no entry and was blank; -Noon had no entry and was blank; -Hour of sleep med had no entry and was blank; -10/28/24 showed: -Morning had entry of 9, medication was unavailable; -Noon showed medication was administered. -Started 10/26/24, Methocarbamol oral tablet 750 mg, give 1 tablet by mouth four times a day for muscle spasm; -10/26/24 showed: -8:00 A.M. had no entry and was blank; -12:00 P.M. had no entry and was blank; -4:00 P.M. had no entry and was blank; -8:00 P.M. had no entry and was blank; -10/27/24 showed: -8:00 A.M. had entry of 9, medication unavailable; -12:00 P.M. had entry of 9, medication was unavailable; -4:00 P.M. had entry of 9, medication was unavailable; -8:00 P.M. showed medication was administered; -Started 10/26/24, Alprazolam oral tablet .25 mg, give 1 tablet by mouth every four hours as needed for anxiety, Order discontinued 10/27/24 at 7:07 P.M: -10/26/24 showed: -As needed, had no entry and was blank; -10/27/24 showed: -As needed, had no entry and was blank; -Started 10/27/24, Alpraxolarm oral tablet 25 mg, give 1 tablet by mouth every 8 hours as needed three times a day in the morning, at noon, and bedtime for anxiety, showed: -10/27/24 showed: -PRN - had no entry; -10/28/24 showed: -PRN received at 8:56 P.M. -Started 10/26/24, oxycodone Hcl oral capsule 5 mg, give 1 capsule by mouth ever 4 hours as needed for pain, discontinued 10/27/24 at 9:06 P.M.: -10/26/24 -PRN as needed had no entry and was blank; -Started 10/27/24, oxycodone hcl oral tablet 5 mg, give 1 tablet by mouth every hours as needed for severe pain (8-10) for up to 3 days until 10/30/24 at 11:59 P.M.: -10/27/24 -PRN was blank and had no entries; -10/28/24 -PRN received at 3:46 P.M; Review of electronic medical record, showed -On 10/25/24, resident was admitted to facility census; -On 10/25/24 2:06 P.M., Licensed Practical Nurse (LPN) A wrote resident arrived via emergency medical services stating he/she was in moderate pain with a script for oxycodone. -On 10/26/24 11:10 P.M., LPN B wrote resident vocalized pain as primary issue with pain score of 7 with pain being sharp, aching, and radiating. Pain note showed that resident's pain medication was pending due to needing doctor approval signature. -On 10/27/24 at 12:19 A.M. LPN B wrote resident was having discomfort due to recent vehicular accident; -On 10/27/24 at 10:22 A.M., RN B wrote resident had non verbal sounds, protective body movements, vocal complaints of pain. Pain was located in several areas throughout the body. The first area was frontal area as sharp, aching, non radiating with the frequency being intermittent. A cool compress was applied and distraction techniques were utilized. Residents as needed medication were given. The second pain area was resident's chest with generalized pain score of 8 described with stiffness, worse with movement and frequency being daily. Third location was his/her right knee with a pain score of 8 described as stabbing, aching, burning, sharp, and worse with movement with the frequency being constant. Fourth location was his/her left knee with pain score of 8 which was sharp, aching, stabbing, burning, stiff, and worse with movement and the frequency was constant. The fifth pain location was lower leg with a pain score of 9 that was described as sharp, aching, stabbing, radiating, with frequency of his/her pain being constant. The sixth pain location was right anterior elbow with pain score of 4 that was burning, non radiating, and the frequency was intermittent. Resident had fractured left ankle, laceration to left knee with six sutures in place, scabbed abrasion to right knee, two round areas on right elbow with the first layer of skin missing. -On 10/27/24 at 4:50 P.M. RN B wrote that the primary care provider was notified of situation with resident not having narcotic medications since arrival to facility on Friday 10/25/24. Orders obtained to change Alprazolam .25 mg three times a day as needed, oxycodone 5 mg every 4 hours as needed for severe pain (8-10) for three days. -On 10/27/24 at 5:15 P.M., narcotic pain medication was delivered from pharmacy. During an interview on 11/4/24 at 8:08 A.M., RN B said: -Resident #1 admitted to facility approximately 2:30 P.M. on 10/25/24 from the hospital after having been in a car accident; -Resident #1 had been receiving oxycodone, Xanax, and other medications to manage his/her pain levels; -When he/she arrived for his/her shift on 10/27/24 resident had not received any of his/her pain medications; -Resident #1 was in pain and very anxious; -Resident #1's blood pressure was extremely high due to his/her pain level; -He/She contacted the primary care provider who did not know resident had entered facility; -Primary Care Provider was very upset resident had entered facility and had not received his/her pain medication; -Orders were showed as still pending in the electronic medical record system; -Resident #1 had went two days without pain medication; -He/She attempted to contact Director of Nursing; -He/She was the third Registered Nurse who had interacted with resident since resident had entered the facility on 10/25/24. During an interview on 11/7/24 at 10:08 A.M., Registered Nurse A said: -When a resident is a new admit to facility the new orders are put in and ordered within the first hour of arrival; -If an admission arrived late in the evening will not get medication until the middle of the night; -If the medication is showing up in the electronic medical record as pending it meant the medication is on order; -When a medication had not arrived to facility staff can go in and mark in the medication administration record that the med was not given due to not being available; -He/She would not expect a resident to wait two days to receive a narcotic pain medication upon admission and that would not be acceptable; -Facility did have an emergency medication kit available for staff to obtain medication from; -He/She expected that medications would be received from the pharmacy by that evening if a new admission arrived to the facility by 2:00 P.M.; During an interview on 11/7/24 at 10:15 A.M., Certified Nurse Aide (CNA) A said: -He/She was working the second day after Resident #1 admitted to the facility; -Resident #1 verbalized that he/she had chest pain so he/she told the nurse; -The nurse advised he/she didn't have any medications because the medication scripts had not got transferred over in the electronic medical record; -Resident #1 was unable to receive any of his/her medications on his/her second day in the facility as they were not available in the facility During an interview on 11/7/24 at 10:22 A.M., Certified Medication Technician (CMT) A said: -The facility nurses were responsible for obtaining resident's medications; -The charge nurse should notify the Director of Nursing or Administrator with issues with medications. During an interview on 11/7/24 at 10:38 A.M., CNA B said: -He/She was working Friday, Saturday, and Sunday when resident #1 first admitted to the facility; -Resident #1 arrived to facility approximately 4:00 P.M. on 10/25/24; -The RN on duty was very upset on Saturday as he/she was trying to figure out what to do regarding resident not having medications; -The RN on duty made several calls to Administrator and Director of Nursing; -The RN on duty called the pharmacy a couple of times; -Resident #1 still had no medications available on Sunday 10/27/24; -Resident #1 went Friday evening, all day Saturday, and Sunday without his/her medications; -Resident #1 had his/her call light on entire day on Saturday and Sunday due to having anxiety of not having his/her pain medication which made his/her pain worse; -Resident #1 had a lot of anxiety of not understanding why his/her pain medication was not delivered; -Resident #1's pain was worse on Saturday because his/her pain medication he/she had received before leaving the hospital had worn off; -There was a lot of frustration with all nursing staff that weekend in regards to resident not having his/her medications. During an interview on 11/12/24 at 12:20 P.M., RN C said: -All medications for Resident #1 were showing in the system as pending; -He/She could not access Resident #1's Medication Administration Record at all; -Resident #1 was very anxious and having discomfort and needed his/her medications; -Resident #1 did not receive any of his/her medications at all during his/her shift; -He/She attempted calling Administrator and Director of Nursing several times; -Many times Administrative staff did not call back when he/she called for support; -He/She contacted the pharmacy two to three times but they advised they could not do anything because of the pending status in the electronic medical record. During an interview on 11/12/24 at 12:41 P.M., LPN A said: -When he/she arrived to the facility at 10:00 P.M. on 10/25/24 the admission packet for resident had not been done so he/she worked on packet when he/she arrived; -The hospital did not send a script with him/her for the oxycodone; -He/She did not have any active orders for Resident #1 so he/she gave him/her Tylenol which helped because resident had just come from hospital and still had some pain relief support from pain medication received at the hospital. During an interview on 11/12/24 at 3:55 P.M., Director of Nursing said: -The nurses have a check off list they complete with new admissions which included ordering all medication; -Medication arrivals are dependent on which pharmacy they are using; -The nurse was responsible to order the medication and that is on the admission check list; -He/She would not have expected a resident to go 48 hours without any medications for pain; -Facility had a StatSafe (an electronic emergency /stat-dose cabinet that allows long term care facilities to provide more responsive patient care), but the StatSafe did not have oxycodone in it; -He/She expected that if resident was having pain that the staff follow up on why the pain medication was not in facility and seen if there was any other medication that could have been given for his/her pain; -He/She was not available the weekend Resident #1 admitted ; -He/She did not hear about the pain medication not being available for Resident #1 until 10/29/24 During an interview on 11/12/24 at 3:55 P.M., Administrator said: -He/She received a call on 10/26/24 from RN working regarding Resident #1 and they said he/she had spoken to the pharmacy and the medications would be delivered at the first available time between 4:00 P.M.-6:00 P.M; -He/She did not know resident #1's pain medication did not arrive to facility; -He/She expected staff to obtain medications timely and for residents to have effective pain management. MO244586

Based on observation, interview, record review, and facility policy review, the facility failed to ensure nebulizer tubing and a nebulizer mouthpiece were cleaned after use and stored in a manner to prevent potential contamination between uses for 1 (Resident #22) of 1 resident reviewed for respiratory care. Findings included: A facility policy titled, Departmental (Respiratory Therapy)- Prevention of Infection, revised 11/2011, specified, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. The section of the policy addressing, Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol indicated, 3. After completion of therapy: a. Remove the nebulizer container; b. Rinse the container with fresh tap water; and c. Dry on a clean paper towel or gauze sponge. 4. Reconnect to the administration set-up when air dried. 5. Take care not to contaminate internal nebulizer tubes. 6. Wipe the mouthpiece with damp paper towel or gauze sponge. 7. Store the circuit in plastic bag, marked with date and resident's name, between uses. An admission Record indicated the facility admitted Resident #22 on 06/02/2022. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease, dyspnea (difficult or labored breathing), and mild intermittent asthma. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/19/2024, revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Resident #22's care plan included a focus area, initiated on 07/23/2024, that indicated the resident had altered respiratory status/difficulty breathing related to chronic obstructive pulmonary disease and anxiety. An intervention dated 07/23/2024 directed staff to administer medication/puffers as ordered. Resident #22's Order Summary Report, listing active orders as of 10/08/2024, included an order dated 10/31/2023 for ipratropium-albuterol (a nebulizer solution) 0.5-2.5 milligrams per 3 milliliter vial, one nebulizer treatment every day prior to breakfast related to DYSPNEA. The Order Summary report did not include any orders related to cleaning or storage of the resident's nebulizer tubing or mouthpiece. Resident #22's Nurse Medication Administration Record for 10/2024 revealed the resident was scheduled to receive their ipratropium-albuterol nebulizer treatment each day at 7:30 AM. According to the Nurse Medication Administration Record, Certified Medication Technician (CMT) #4 signed as having administered the resident's nebulizer treatment on the morning of 10/07/2024, and Licensed Practical Nurse (LPN) #10 signed as having administered the resident's nebulizer treatment on 10/09/2024. During a concurrent interview and observation on 10/07/2024 at 10:40 AM, Resident #22 stated they received a nebulizer treatment earlier in the morning. The resident's nebulizer still had the tubing and mouthpiece attached, and the mouthpiece was observed on the bedding of an extra bed in the resident's room. During an observation on 10/07/2024 at 1:15 PM, Resident #22's nebulizer still had the tubing and mouthpiece attached, and the mouthpiece remained directly on the extra bed in the resident's room. During a concurrent interview and observation on 10/07/2024 at 3:21 PM, LPN #9 said CMT #4 administered Resident #22's medications on the morning of 10/07/2024. LPN #9 stated that after a nebulizer treatment was administered, the tubing and mouthpiece should be disconnected, then cleaned and allowed to air dry. During the interview, Resident #22's nebulizer still had the tubing and mouthpiece attached, and the mouthpiece remained directly on the extra bed in the resident's room. During an interview on 10/09/2024 at 1:58 PM, CMT #4 said that after a nebulizer treatment was complete, the tubing and mouthpiece should be disconnected, cleaned, allowed to air dry, then reconnected and hooked to a latch on the side of the nebulizer machine. CMT #4 said Resident #4's nebulizer mouthpiece should not have been on the bed, but she forgot to clean it. During a concurrent observation and interview on 10/09/2024 at 10:25 AM, Resident #22's nebulizer machine was on the resident's bed with the tubing and mouthpiece attached, resting directly on the bedding. Resident #22 said they had completed their nebulizer treatment, but the nurse had not been back in the room. During an interview on 10/09/2024 at 11:30 AM, LPN #10 said she administered Resident #22's nebulizer treatment before breakfast but had not been back to the resident's room. LPN #10 said the nebulizer tubing and mouthpiece should be cleaned, then stored inside a cubby hole on the nebulizer machine. During an interview on 10/10/2024 at 1:35 PM, the Regional Nurse indicated that following a nebulizer treatment, the nebulizer equipment should be cleaned and placed on a towel to dry to prevent potential infections. The Regional Nurse said Resident #22's nebulizer mouthpiece should not have been on the bed in the resident's room. During an interview on 10/10/2024 at 2:17 PM, the Administrator stated nebulizer mouthpieces should not be placed on residents' beds; they should be cleaned and put away.

Based on interview and record review, the facility failed to provide personal funds and a final accounting within thirty days upon discharge. This affected two of five sampled residents (Resident #1 and #2) Facility census was 38. Review of facility policy, Conveyance upon discharge, eviction, or death policy, dated 2019, showed: -Upon discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility shall convey within 30 days the resident's funds and final accounting of those funds, to the resident, his or her legal representative, or in the case of death, the individual, or probate jurisdiction administering the resident's estate, in accordance with state law. 1. Review of the facility's interim aging report, dated 8/21/24, showed the following residents had money in the facility's operating account: -Resident #1 discharged on 2/1/24, with a balance of $2,428.00; -Resident #2 discharged on 7/9/24, with a balance of $5,531.46. Review of Request for Resident Refund invoices showed: -On 7/16/24, Business Office Manager (BOM) submitted invoice #134 to corporate office to refund $2,428.00 -On 7/16/24, BOM submitted invoice #133 to corporate office to refund $3,855.26. 2. During an interview on 8/21/24 at 4:07 PM with the Business Office Manager (BOM) said: -He/She created invoices and submitted them to corporate office for payments; -He/She submitted invoice to corporate for Resident #1 and Resident #2 on 7/16/24; -Corporate printed check on 8/14 for Resident #1 in the amount of $2428.00 and they did not sign the check; -He/She did not mail Resident #1's check due to not having a signature; -He/She had contacted the Accounts Payable staff member at corporate office on 8/19/24 regarding the unsigned check and they said the check would be available by 8/21/24; -He/She had not yet received the signed check for Resident #1 as of 8/21/24 at 4:07 P.M.; -He/She had not received a check for Resident #2 after submitting invoice on 7/16/24; -He/She expected resident funds to be returned within 30 days; -He/She submitted During an interview on 8/22/24 at 1:26 PM the Administrator said: -He/She expected the facility to follow the facility policy to return resident funds within 30 days of discharged ; -His/Her staff submitted resident invoice in a timely manner but corporate failed to cut check within 30 day timeline. MO240773

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure they provided a notice before transfer and/or discharge for one of 12 sampled residents (Resident #2) when they transferred the resident to the hospital. The facility census was 30. Review of the undated Facility Initiated Transfer or Discharge of Resident policy, showed on occasion, residents may be transferred or discharged for various reasons and these transfers and discharges may be initiated by the facility. The facility may initiate transfer or discharge for the following reasons including the transfer or discharge is necessary to meet the resident's welfare and the resident's welfare cannot be met in the facility. The procedure included: - Should the facility determine that transfer/discharge is necessary, the facility shall complete the following: *Resident, family and/or legal representative will be given 30 day notice prior to transfer or discharge when a resident's urgent medical needs require more immediate transfer; - The policy did not indicate the procedure staff should utilize when a resident is transferred to the hospital in an emergent situation. Review of Resident #2's significant change in condition Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/3/21, showed the resident was admitted to hospice. Review of the resident's electronic medical record showed staff sent the resident to the hospital in November 2021. The resident readmitted to the facility on [DATE] on Hospice. Staff did not document they provided a discharge/transfer notice to the resident or his/her legal representative prior to being transferred to the hospital. During an interview on 3/15/22 at 4:27 P.M., the resident's daughter said staff called her immediately to notify her that the resident was not well when he/she had his/her stroke. He/she had been at the facility for physical therapy and just declined since then. When they sent him/her to the hospital, they did not give her a notice in writing that they were transferring the resident, they only called. Once the resident readmitted to the facility, he/she was on Hospice. During an interview on 3/21/22 at 2:50 P.M., the acting Director of Nursing (DON) who worked as the day shift charge nurse three days a week said they should be sending the discharge letters whenever a resident is sent to the hospital. They have a form letter that is sent with the resident. Staff should document in the record they sent the letter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure they provided a notice of their bed-hold policy before transferring for one of 12 sampled residents (Resident #2) when they transferred the resident to the hospital. The facility census was 30. Review of the facility's September 2017 Bed Hold/readmission Policy showed to comply with Federal rules, this facility is giving the letter to you and/or your resident representative at this time to inform you of the policy on bed holds and readmission to our facility. Residents and the resident representative will be sent a letter each time one of the following events take place: - Resident is transferred to the hospital; - Resident goes on a therapeutic visit; - Facility determines that a resident, who was transferred with an expectation of returning to the facility, cannot return and the facility shall initiate the notice of discharge. Review of Resident #2's significant change in condition Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/3/21, showed the resident was admitted to hospice. The facility did not complete an entry or discharge MDS when the resident was sent to the hospital. Review of the resident's electronic medical record showed staff sent the resident to the hospital in November 2021. The resident readmitted to the facility on [DATE] on Hospice. Staff did not document they provided the bed hold/readmission policy to the resident or his/her legal representative prior to being transferred to the hospital. During an interview on 3/15/22 at 4:27 P.M., the resident's daughter said staff called her immediately notify her that the resident was not well when he/she had his/her stroke. He/she had been at the facility for physical therapy and just declined since then. When they sent him/her to the hospital, they did not give her a bed hold/readmission policy letter. Once the resident readmitted to the facility, he/she was on Hospice. During an interview on 3/21/22 at 2:50 P.M., the acting Director of Nursing (DON) who worked as the day shift charge nurse three days a week said they do not send the bed-hold letter/policy with residents that she is aware of when a resident is sent to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure they completed an accurate comprehensive assessment which reflected residents' status for one of 12 sampled residents (Resident #25). The facility census was 30. The facility did not provide a policy on completing the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, for residents. Review of Resident #25's annual MDS, dated [DATE], showed: - A Brief Interview for Mental Status (BIMS) score of 5, indicating moderate cognitive impairment; - No behaviors, such as physical or verbal behavioral symptoms directed towards others, did not reject care, and no change in current behavior status. - Independent with all activities of daily living (ADLs); - Always continent of bowel and bladder; - No falls since prior assessment.; - No ulcers, wounds and skin problems. Review of the resident's behavior flow sheet showed staff documented the following: - The resident was agitated 19 times between 11/12/21 and 2/4/22; - The resident was irritable 17 times between 11/12/21 and 2/4/22; - The resident was attention seeking three times between 11/12/21 and 2/4/22; - Self-injurious eight times between 11/21/21 and 2/4/22; on these dates, staff indicated the resident was at significant risk for physical illness or physical injury. Review of the post fall evaluation, dated 12/21/21 showed: - Date and time of fall: 12/21/21 at 6:30 P.M.; unwitnessed; - Fell in resident room; found on floor; - No apparent injury; - History of fall in last three months: Yes. Review of the post fall evaluation, dated 12/30/21 showed: - Date and time of fall: 12/30/21 at 6:55 A.M.; unwitnessed; - Fell in resident room; footwear not non-slip, from regular bed; - No apparent injury; - History of falls in the last three months: No. Review of the post fall evaluation, dated 1/6/22, showed: - Date and time of fall: 1/6/22 at 8:55 A.M.; witnessed; - Fell in hallway from standing position; - Hit head, hematoma, treatment in facility; - History of falls in the last three months: Yes. Review of the post fall evaluation, dated 1/28/22, showed: - Date and time of fall: 1/28/22, at 7:40 A.M.; unwitnessed; - Fell in resident room, found on floor; - Hematoma, skin tear, treatment in facility; - History of falls in last three months: Yes. Review of the nursing home documentation form, dated 1/26/22, showed the physician saw the resident in the facility. He/she noted on the assessment the resident had infected open areas on his/her face. The resident was started on cephalexin (an antibiotic) 500 milligrams three times a day for seven days. Review of the resident's quarterly MDS, dated [DATE], showed: - A BIMS score of 3, indicating severe cognitive impairment; - No behaviors, such as physical or verbal behavioral symptoms directed towards others, did not reject care, and no change in current behavior status; - Independent with most ADLs except walking in corridor and eating where he/she now required supervision only; - Occasionally incontinent of bladder and always continent of bowel; - Two falls since previous assessment; - No ulcers, wounds and skin problems; - Had not received any antibiotics in the previous seven days. During an interview on 3/16/22, at 1:18 P.M., the Registered Nurse (RN) B/MDS coordinator said she works overnight three nights a week. She completes her MDS assessments in pieces, when she has time. She uses other nurses' notes and their report to see changes in residents. She does the best she can with the time she is in the facility. She works the floor so she knows of new orders. She has been here two and half years as MDS coordinator. She is doing what she can to keep MDS updated. The acting Director of Nursing (DON) used to be MDS coordinator and can do back up as needed if she is not here or available. She also gets notified of changes during shift change report. Monday-Friday when doing MDS attends pm report. During an interview on 3/21/22 at 2:50 P.M., the acting DON said RN B ask her to look at MDS, in contact with [NAME] City. They do not have anyone who looks at the MDS on a weekly basis. It is an expectation that they are a true picture of the resident since the last MDS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and closed record review , the facility failed to ensure staff completed a comprehensive discharge summary for one of the two sampled closed records (Resident #9) to include appropriate information about the resident's diagnosis, course of illness/treatment or therapy, a post discharge plan of care to assist the resident to adjust to his/her new living environment when applicable. The facility census was 30. Review of facility policy titled Discharge Planning Policy, undated, showed the following: -To complete discharge planning on any resident where discharge is anticipated to home, another skilled nurse facility/nursing facility or other type post acute setting. -Discharge planning is a patient centered, interdisciplinary process that begins with an initial assessment of the residents potential needs at the time of admission and continues throughout the resident's stay. -Resident's and representatives should be informed of the appropriate community resources available and encouraged to participate in the discharge planning process. -Referrals to community providers will occur in a timely, systematic fashion that assist the resident and resident representative in gaining services and transitioning to the least restrictive level of care and keeping with the resident's wishes. Review of Resident #9's electronic medical record showed: - Date of admission on [DATE] - discharge on [DATE] - Staff did not document any information in the section record titled Discharge Summary and Recaptiulation. - The record did not include the required information for the resident's stay at the facility. - The record did not include communication with the receiving facility regarding the resident. - The record did not include a discharge order from resident's physician. During interview on 3/17/22 at 1:50 P.M., Registered Nurse (RN) A, said after printing the discharge summary and recaptipulation, staff did not documentnt any information regarding the resident's stay or his/her discharge information. notes were made on facility documentation. During an interview on 3/21/22 at 2:50 P.M., the acting Director of Nursing (DON) said the discharge summaries used to be started by the previous social services staff. She and the MDS coordinator would plug information in on the discharge work flow sheet in the electronic medical record. Discharge summaries and recapitulations should be completed when a resident discharges.

Based on observations, record review and interviews, the facility failed to follow safety standards and policy for one of 12 sampled residents (Resident #1) who had no smoking assessment. Facility census was 30. Review of facility policy Smoking Policy dated October 2017 showed in part: -Any resident who smokes shall be assessed for their ability to smoke safely unsupervised. Assessments shall be conducted upon admission, quarterly and with changes in condition. -The assessment shall include cognition, communication/vision/hearing, physical abilities, safety risk history, and observations of smoking history. 1. Review of Resident #1 quarterly Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff) dated 3/8/22 showed: -Brief Interview of Mental Status (BIMS) of 5. (this indicates moderate to severe cognitive impairment). -Diagnosis of Alzheimer's Dementia and Dementia with Behavioral Disturbance. -Needs supervision of staff with dressing and hygiene. Review of the resident's Care Plan dated 11/26/21 showed -Cognitive Defect: break things down into simple tasks. -Likes to be independent with Activities of Daily Living but may need assistance. -Alert with confusion, forgets he/she went to smoke and becomes agitated. Review of Resident #1 medical record showed: -No completed smoking assessment. During an interview on 3/17/22 at 3:22 P.M. Registered Nurse (RN) A said: -Resident #1 does not have a smoking assessment for safety. -Smoking assessments should be done with each MDS. -He/she expects smoking/safety assessments to be completed on any resident who smokes.

Based on record review and interviews, the facility failed to ensure residents remained free from unnecessary drugs when staff failed to discontinue the use of as needed (PRN) opioids after 14 days or have the physician reassess the appropriateness of the continued use of the medication for one of 12 sampled residents (Resident #2). The facility census was 30. The facility did not provide a policy to address the use of unnecessary drugs and discontinuing PRN opioids after 14 days. 1. Review of Resident #2's significant change in condition Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 12/3/21 , showed: - Long and short-term memory problems; - Extensive staff assistance with bed mobility, transferring from one surface to another, dressing, toilet use and personal hygiene; - Diagnoses included: Alzheimer's disease, - Not on scheduled pain medication, PRN medication and not received any non-medication interventions for pain; no presence of pain; - Had not received any opioids in the previous seven days; - Hospice. Review of the resident's current care plan, printed on 3/16/22, showed: - Problem: I am on hospice. Please contact them with any changes in condition; start date 11/24/21; staff did not add any goals. - The section for pain was blank with no problem listed and no goals. Review of the resident's January 2022, medication administration record (MAR) showed: - Morphine 5 milligrams (mg) sublingual (sL), every hour PRN, order date 11/24/21; - Staff had not administered the medication during the entire month of January. Review of the resident's February 2022, medication administration record (MAR) showed: - Morphine 5 mg sL, every hour PRN, order date 11/24/21; - Staff had not administered the medication during the entire month of February. Review of the resident's current, March 2022, physician's order sheet (POS) showed: - Morphine 5 mg sL, every hour PRN, order date 11/24/21. Review of the resident's current, March 2022, medication administration record (MAR) showed: - Morphine 5 mg sL, every hour PRN, order date 11/24/21; - Staff had not administered the medication from 3/1/22 through 3/21/22. During an interview on 3/21/22 at 10:42 A.M., Registered Nurse (RN) A said PRN orders for opioids should not be entered without a stop date. These medications should be for a 14 day duration only. This resident is on hospice so the order must have been entered when he/she was admitted to hospice. They expect the pharmacy to help monitor for this as well as whoever is reconciling orders for the month. During an interview on 3/21/22 at 2:50 P.M., the acting Director of Nursing (DON) said ensuring they are looking at gradual dose reductions and PRN orders for opioids and psychotropic medications is a conjoined effort because there is not someone in the DON office 100% of the time. They need to do more education with nursing staff to ensure they are only entering PRN orders for 14 days and ensuring they contact the physician to renew the orders. When the pharmacy comes in, the MDS coordinator goes through the recommendations and puts them on the clip board for the physician to review.

Based on record review and interviews, the facility failed to ensure residents remained free from unnecessary drugs when staff failed to discontinue the use of as needed (PRN) psychotropic medications after 14 days or have the physician reassess the appropriateness of the continued use of the medication and failed to ensure they attempted an gradual dose reduction (GDR) in an effort to discontinue psychotropic drug use, unless clinically contraindicated for one of 12 sampled residents (Resident #2). The facility census was 30. The facility did not provide a policy to address the use of unnecessary drugs, gradual dose reductions and discontinuing PRN opioids after 14 days. 1. Review of Resident #2's significant change in condition Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 12/3/21 , showed: - Long and short-term memory problems; - Extensive staff assistance with bed mobility, transferring from one surface to another, dressing, toilet use and personal hygiene; - Diagnoses included: Alzheimer's disease; - Exhibited behavior symptoms such as physically directed towards others and verbally towards others one to three days in the assessment period; - Received antipsychotic medications five of the previous seven days, antianxiety medications one of the previous seven days, antidepressent medications five of the previous seven days; - Antipsychotic medication review: received antipsychotics on a routine basis only; no PRN received; - Have not attempted a GDR; - GDR has not been documented by a physician as clinically contraindicated; - Hospice. Review of the resident's current care plan, printed on 3/16/22, showed: - Problem: I am on hospice. Please contact them with any changes in condition; start date 11/24/21; staff did not add any goals. - Problem: I take psychotropic medications; start date 12/3/21; *Please administer my medication as prescribed by my physician; *Please monitor for any changes in cognitive status and report any changes to the charge nurse; *Please monitor for any mood changes and report them to the charge nurse; *I sometimes refuse my medications. Either have another nurse administer my medications or come back after a few minutes and try again; *I have times during the day where I become irritable. Please offer reassurance and comfort when this happens; - The plan did not offer any other interventions that were non-pharmacological to help combat the resident's behaviors, did not address the use of PRN medications past 14 days and did not address attempting GDR. Review of the telephone order sheet (TOS) dated 1/21/22, showed: - Haldol (antipsychotic used to treat certain types of mental disorders) 5 milligrams (mg) intramuscularly (IM) times one now; order received at 4:55 P.M.; - Ativan (lorazepam, can treat seizure disorders, such as epilepsy) 2 mg IM times one; order received at 5:33 P.M.; - The Ativan order did not indicate staff could administer the IM medication after the one time dose or to keep the medication as a PRN medication. Review of the resident's March 2022, medication administration record (MAR) showed: - Sertraline (used for depression) 50 mg tablet, daily at hour of sleep (HS); start date 7/20/21; - Quetiapine (Antipsychotic used to treat schizophrenia, bipolar disorder, and depression) 75 mg tablet orally daily at 4:00 P.M.; indication dementia; order date 9/28/21; - Quetiapine 100 mg tablet orally daily at 8:00 P.M.; indication agitation; order date 9/28/21; - Quetiapine 50 mg tablet orally daily at 12:00 P.M.; indication agitation; order date 9/28/21; - Lorazepam 2 mg injection IM once for agitation/anxiety; as needed for anxiety; start date 1/21/22; with no stop date entered; this medication had not been administered between 3/1/22 and 3/21/22. Review of the Flowsheet Print Request of the resident's medication administration, printed by facility staff showed: - Lorazepam 2 mg IM, Form: injection, Once PRN as needed for anxiety; - First dose 1/21/22 5:32 P.M.; - Indication agitation anxiety; - Last given: 3/15/22 at 8:16 P.M. During an interview on 3/21/22 at 10:42 A.M., Registered Nurse (RN) A said PRN orders for opioids should not be entered without a stop date. These medications should be for a 14 day duration only. This resident is on hospice so the order must have been entered when he/she was admitted to hospice. They expect the pharmacy to help monitor for this as well as whoever is reconciling orders for the month. During an interview on 3/21/22 at 2:50 P.M., the acting Director of Nursing (DON) said ensuring they are looking at gradual dose reductions and PRN orders for opioids and psychotropic medications is a conjoined effort because there is not someone in the DON office 100% of the time. They need to do more education with nursing staff to ensure they are only entering PRN orders for 14 days and ensuring they contact the physician to renew the orders. When the pharmacy comes in, the MDS coordinator goes through the recommendations and puts them on the clip board for the physician to review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #22 Quarterly MDS dated [DATE] showed: -BIMS of 3 (indicates severe cognitive loss) -Diagnosis of Congestive Heart Failure, Dementia and Neurogenica Bladder -Needs extensive assistance to total dependence on staff for ADLs. -Hospice Care Review of Resident's Hospice orders showed: -Admit to Hospice care on 10/25/21 -Diagnosis of Acute Diastolic Heart Failure (the left side of the heart stiffens and cannot pump blood throughout the body) and Nonreheumatic mitral valve disorder (the mitral valve doesn't close and allows blood to flow back into the heart) Review of Resident's Care Plan dated 12/31/21 showed: -Resident is on Hospice Care. -The resident did not have a care plan related to the diagnosis for hospice care and any related care that was to be provided. 3. During an interview on 3/21/22 at 2: 47 P.M. the acting Director of Nursing said: -Any changes or resident specific information is placed on a charting log/report document, i.e an admission to Hospice. -The MDS Coordinator is responsible for checking the log and putting any pertinent information into the care plan. -He/she expects Hospice to keep the care plan updated with their responsibilities. -He/she expects the care plan to define what Hospice and facility staff are responsible for. Based on interview and record review, the facility failed to collaborate with hospice in the development of a coordinated plan of care for residents receiving hospice care. This affected two of 12 sampled residents. (Resident #2 and #22). The facility census was 30. Review of the undated Comparison of Facility/Hospice Responsibilities, part of the facility's contracted agreement with hospice providers showed: - Hospice plan of care (HPOC) must identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have ben agreed upon and included in the HPOC. - HPOC reflects participation by the hospice, facility, patient and patient's family. - Discussions of changes to the HPOC with the facility or patient; - Approval by Hospice of any changes to the HPOC prior to implementation. 1. 1. Review of Resident #2's significant change in condition Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 12/3/21, showed: - Long and short-term memory problems; - Extensive staff assistance with bed mobility, transferring from one surface to another, dressing, toilet use and personal hygiene; - Diagnoses included: Alzheimer's disease; - Hospice. Review of the resident's current care plan, printed on 3/16/22, showed: - I am on hospice. Please contact them for any changes in condition, start date 11/24/21; - The care plan did not indicate what services the facility will be responsible for and what the hospice would be responsible for. Review of the resident's hospice book, located at the nurses' station showed a Patient Changes Document (PCD) dated 2/2/22 through 2/16/22. No other copies of this could be found in the book. The PCD gave specific direction of what services they would be responsible for, but did not indicate what services the facility staff would be responsible to do.

Based on observation, interview, and record review, the facility failed to ensure staff who are not up-to-date with COVID-19 vaccination were routinely tested for COVID-19 according to their policy and county transmission rate. This affected four staff members and had the potential to affect all residents. The facility census was 28. 1. Review of the facility's policy titled COVID-19 Vaccination Policy, dated 2/2022, showed the following: - Purpose- In accordance with the facility's duty to provide and maintain a workplace that is free of known hazards, the facility was adopting the policy to safeguard the health of the employees and their families, customers and visitors and the community at large from the COVID-19 virus, that may be reduced by vaccinations. This policy will comply with all applicable laws and is based on guidance from the Centers for Disease Control and Prevention (CDC), Centers of Medicare and Medicaid Services (CMS), and local Health authorities; - Scope- All employees are required to receive the COVID-19 vaccination as determined by CMS, unless a reasonable accommodation is approved. Employees not in compliance with this policy will be placed on unpaid leave until their employment status is determined by facility. -Additional precautions and contingency plans for those staff who are unvaccinated include at least weekly testing or more frequently based on community positivity rate. 1. During an interview on 6/25/22 at 3:30 P.M. the Administrator said: -The facility is testing unvaccinated and not fully vaccinated staff two times a week per the county positivity rate. Testing is done on Thursday and Monday; -The facility considers not fully vaccinated as those who have not received a booster. Review of the CDC's COVID-19 level of community transmission rates showed the following: 6/2/22- High (red)- indicating staff who are not up-to-date should test twice a week. 6/6/22-High (red)- indicating staff who are not up-to-date should test twice a week. 6/9/22- High (red)- indicating staff who are not up-to-date should test twice a week. 6/13/22- High (red)- indicating staff who are not up-to-date should test twice a week. 2. Review of Nurse Aide (NA) A Covid-19 vaccination record showed the employee has received two doses of a Covid-19 vaccine but no booster. Review of Employee's schedule showed: - the employee worked 6/2/22, off 6/3/22 through 6/6/22. -Worked 6/7/22 and off 6/8/22 and 6/9/22; -Worked 6/12/22 and off 6/13/22. Review of the facility Employee Covid Testing worksheets showed: -Testing date of 6/2/22 with no Covid test done; -Testing date of 6/6/22 with no Covid test done: -Testing date of 6/9/22 with no Covid test done; -Testing date of 6/13/22 with no Covid test done. 3. Review of Certified Nurse Aide (CNA) A Covid-19 vaccination record showed the employee has received two doses of a Covid-19 vaccine but no booster. Review of the Employee's schedule showed: -the employee worked on 6/1/22, 6/4/22, 6/4/22, 6/7/22, 6/8/22, 6/13/22. Review of the facility Employee Covid Testing worksheets showed: --Testing date of 6/2/22 with no Covid test done; -Covid test done on 6/5/22 with negative results; -Testing date of 6/6/22 with no Covid test done: -Testing date of 6/9/22 with no Covid test done; -Testing date of 6/13/22 with no Covid test done; -Covid test done on 6/14/22 with negative results. 4. Review of Housekeeper A Covid-19 vaccination record showed the employee has received two doses of a Covid-19 vaccine but no booster. Review of the Employee's schedule showed: -Worked on 6/1/22, 6/2/22, 6/3/22, 6/6/22, 6/7/22, 6/11/22 and 6/13/22. Review of the facility Employee Covid Testing worksheets showed: -Testing date of 6/2/22 with no Covid test done; -Testing date of 6/6/22 with no Covid test done: -Testing date of 6/9/22 with no Covid test done; -Testing date of 6/13/22 with no Covid test done. 5. Review of Employee #4's Covid-19 vaccination record showed the employee has received two doses of a Covid-19 vaccine but no booster. Review of the Employee's schedule showed: -Worked on 6/1/22, 6/3/22, 6/6/22, 6/8/22, 6/10/22, 6/11/22, and 6/13/22. Review of the facility Employee Covid Testing worksheets showed: -Testing date of 6/2/22 with no Covid test done. During an interview on 6/15/22 at 5:00 P.M. the Administrator said: -Covid-19 testing is done two times a week on Monday and Thursday's; -If an employee is not working on those days, then they should be tested the next day they come into work.

Based on observation, interview and record review, the facility failed to fully develop and implement their staff vaccination policy for COVID-19 when they did not ensure all required components were included in the policy and failed to implement a process for tracking and documenting the COVID-19 vaccination status for all staff. Facility census was 30. 1. Review of the facility's policy titled COVID-19 Vaccination Policy, dated 2/2022, showed the following: - Purpose- In accordance with the facility's duty to provide and maintain a workplace that is free of known hazards, the facility was adopting the policy to safeguard the health of the employees and their families, customers and visitors and the community at large from the COVID-19 virus, that may be reduced by vaccinations. This policy will comply with all applicable laws and is based on guidance from the Centers for Disease Control and Prevention (CDC), Centers of Medicare and Medicaid Services (CMS), and local Health authorities; - Scope- All employees are required to receive the COVID-19 vaccination as determined by CMS, unless a reasonable accommodation is approved. Employees not in compliance with this policy will be placed on unpaid leave until their employment status is determined by facility. Further review of the facility's policy titled COVID-19 Vaccination Policy, dated 2/2022, showed the policy was missing the following required components: o A process to ensuring all required staff (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations), have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the facility and/or its residents; o A process ensuring that all required staff are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; o A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19 for all staff who are not fully vaccinated for COVID-19; o A process for tracking and securely documenting the COVID-19 vaccination status of all required staff; o Contingency plans for staff who are not fully vaccinated for COVID-19. 2. Review of the COVID-19 Employee Vaccination list document that was provided by facility staff on 3/14/22 showed the names on the document did not match the staff roster provided by the facility. -Two facility direct hire staff were not listed on the facility provided vaccination matrix, although they were included on the staff roster, and the facility could not prove vaccination status: -Dietary Aide A -Cook A -Two names noted on the facility provided vaccination matrix were not listed on the facility provided direct hire/contracted staff list -Certified Nurse Aide (CNA) A -One facility staff member on the facility provided vaccination matrix had no proof of vaccination status. -CNA B Review of the facility's COVID-19 staff vaccination documentation showed, the facility had 42 employees. Documentation showed 95% of employees were fully vaccinated, had a pending or approved exemption, or had a CDC recognized temporary delay for vaccination. Review of the facility's COVID-19 documentation showed no positive resident cases in previous 4 weeks. During an interview on 03/16/22 at 1:18 P.M. Registered Nurse B (infection preventionist) said: -He/she is not responsible for the COVID 19 vaccination matrix. -The Administrator is responsible for the COVID 19 vaccination matrix. During an interview on 3/16/22 at 3:29 P.M. the Administrator said: -He/she hires or provides final approval for all staff hires. -He/she asks for immunization paperwork during pre-employment interviews. -During orientation the new hires vaccination card is copied or exemption paperwork is given to the new hire. -Exemption requests have to go to Corporate office for approval. Staff are not placed on schedule until approval is obtained. - He/she places new staff on the COVID vaccination spreadsheet . -The Business Office Manager places new staff on the staff list. -Dietary Aide A is not a facility employee, he/she is the child of a corporate nurse, was used during COVID crisis and has not been utilized for at least 2 years. -Cook A is an active employee, has been working, and was hired prior to the vaccination mandate. He/she is unsure why [NAME] A is not on the vaccination matrix. -CNA A employment was ended last week. He/she is unsure of exact date. -CNA B employment was ended 3/16/22. -He/she updates the vaccination list and the NHSN data weekly. During an interview on 3/21/22 at 3:42 P.M. CNA D said: -He/she is vaccinated. -He/she wears a procedure mask. -Unvaccinated staff wear N-95 masks. -COVID testing is done twice a week. During an interview on 3/21/22 at 3:47 P.M. CNA E said: -He/she is not vaccinated. -He/she wears a N-95 mask at all times. -He/she tests twice weekly. During an interview on 3/21/22 at 3:52 P.M, Nurse Aide (NA) A saide: -He/she is not vaccinated. -He/she wears a N-95 mask at all times. -He/she does not currently test due to COVID positive in the last 90 days.

Based on observation and interview, the facility failed to ensure the corridor was equipped with firmly secured handrails and handrails are in good repair on one side of the hall. The facility census was 30. Observations on 3/14/22 at 2:20 P.M. showed: - On the 200 hall, first handrail at central bath was loose. - The handrail by the soiled utility room is loose and cracked with jagged edges. During an interview on 3/21/22 at 2:05 P.M. the Maintenance Director said: - He/she does not do rounds and check handrails. - He/she was unaware some needed repaired; - Handrails should not be jagged or loose since the residents use those to stabilize when walking down the halls During an interview on 3/21/22 at 4:19 P.M., the Administrator said handrails should be checked and maintained in good condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure they did not hold residents' monies separate from facility money when they did not reimburse residents and/or their responsible parties after the residents were discharged , which affected six residents sampled for resident trust fund (RTF) review (Residents #30, #31, #32, #33, #34 and #80). The facility's census was 30. Review of the Personal Funds Agreement, dated 2016, showed: - The facility offers the service of holding and managing residents' personal funds. Residents are not required, however to deposit their personal funds with us. They may manage their own funds or have a family member or other person do so. - I understand that within five (5) days of my discharge from the facility, an up to date accounting and the balance of my personal funds will be given to me, my guardian/conservator or any other person I designate in writing. - I understand that if I die with money in my personal funds account if I have received any Medicaid benefits during my lifetime, Missouri law requires the facility to file a report with the Missouri Medicaid program about the balance of my personal funds. The Medicaid Program will then order the facility to send Medicaid the remaining funds. - If I have not received any Medicaid benefits during my lifetime ,then the facility will provide an accounting of the balance of my personal funds account and will release the balance to the personal representative of my estate. If no such personal representative is appointed the funds will be distributed and an accounting provided in accordance with valid order issued by the Probate Division of the Circuit Court. - The form did not address what the facility's responsibility for any resident money paid for room and board and held in the facility's operating account. Review of the facility's [NAME] Aging Report Age Date Thursday, 3/17/22, showed: - Resident #30 (discharged [DATE]) had a negative balance of -$117.00 in the facility's operating account; - Resident #31 (discharged [DATE]) had a negative balance of -$153.00 in the facility's operating account; - Resident #32 (discharged [DATE]) had a negative balance of -$143.00 in the facility's operating account; - Resident #80 (discharged [DATE]) had a negative balance of -$175.00 in the facility's operating account; - Resident #33 (discharged [DATE]) had a negative balance of -$270.00 in the facility's operating account; - Resident #34 (discharged [DATE]) had a negative balance of -$274.50 in the facility's operating account. Review of the Request for Resident Refund forms showed: - All refund requests received in Corporate Office by the 20th of the month will be paid in that month; - Staff completed the form for Resident #80 on 2/3/22 in the amount of $175.00; - Staff completed the form for Resident #34 on 2/15/22 in the amount of $274.50. During an interview on 3/21/22 at 2:13 P.M., the Business Office Manager said residents who have a negative balance on the aging report are all discharged . She has to send the requests for refunds to their corporate office to get them refunded. She knows that Resident #80's had just been done recently so it will take a while. She did not know they needed to be refunded in 30 days or that it was co-mingling. She did not know why they had some that were so old on the report.

Based on record review and interviews, the facility failed to ensure they maintained a surety bond in an amount to cover any loss of theft to residents' money held in the facility's Resident Trust Fund (RTF) account which affected all residents who had money held in their RTF account. The facility's census was 30. Review of the facility's approved surety bond, approved 7/29/20, showed an approved amount of $15,000.00. Review of the RTF worksheet, completed with the Business Office Manager, on 3/21/22, showed: - The average monthly balance for the facility's interest bearing account and petty cash account of $12,580.84; - The approved bond amount for this average monthly balance (Grand Total rounded to the nearest thousand x 1.5 = required bond amount) should be at least $18, 871.50; $3871.50 more than the approved amount. During an interview on 3/21/22 at 2:13 P.M., the Business Office Manager said she completed the form and found they had the correct amount, but did not use the appropriate amount when figuring the ending balance for the petty cash account each month. The facility raised the bond in 2020 when the residents all got the government stimulus checks but she can see now that they need to raise it again.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #1 Quarterly MDS, dated [DATE] showed: -BIMS of 5. (indicates severe cognitive dysfunction). -Diagnosis of Alzheimer's Dementia and Other Dementia with behavioral disturbances. -Resident needs supervision with dressing and hygiene. -Activity preferences include: books, magazines, music and being outside. Review of Resident #1 Care Plan dated 11/26/21 for Mood and Behavior showed: -He/she is alert with confusion. -Simplify tasks to maximize resident's involvement. -Report any episodes of irritability and behaviors to the charge nurse. -He/she forgets he/she went to smoke and becomes agitated with staff. -Reorient him/her as needed and be specific with the next smoke time. -No specifics on behaviors or staff interventions to ensure resident safety -No care plan for activities specific to him/her. 3. Review of Resident # 27 Quarterly MDS dated [DATE] showed: -BIMS of 1 -Diagnosis of Dementia with behavioral disturbance and Diabetes -Resident needs extensive assistance to total dependence with Activities of Daily Living (ADLs) -One Stage III (full-thickness skin loss potentially extending into the subcutaneous tissue layer) pressure ulcer -Activity preferences include: music, animals/pets, books, magazines and going outside. Review of Resident's Care Plan dated 11/26/21 showed: -He/she is alert with confusion. -Reorient him/her to time, person and situation as needed. -He/she is at risk for alterations in skin integrity. -No specifics on behaviors, dementia care or interventions. -No care plan for Diabetes diagnosis and interventions needed to maintain safety and health. -No care plan for activity preferences. 4. Review of Resident # 4 Significant Change MDS dated [DATE] showed: -BIMS of 0 (indicates morbid cognitive loss) -Diagnosis of Sepsis, Urinary Tract Infection and Dementia. -He/she needs extensive assist to total dependence for ADLS. -Activity preferences include: animals/pets and going outside. Review of Resident's Care Plan dated 12/3/21 showed: -Simplify tasks to promote his/her involvement. -Remind him/her to use the call light for assistance. -He/she is alert with confusion. -Reorient him/her to place and time as needed. -Please provide reassurance when he/she is feeling anxious. -No specifics on anxious behaviors or interventions. -No care plan for activity preference. -No specific care plan for urinary tract infections, history of sepsis, treatment or prevention. 5. Review of Resident #22 Quarterly MDS dated [DATE] showed: -BIMS of 3 (indicates severe cognitive loss) -Diagnosis of Congestive Heart Failure, Dementia and Neurogenic Bladder -Needs extensive assistance to total dependence on staff for ADLs. -Activity preferences include: books, magazines, and religious activities. -Hospice Care Review of Resident's Care Plan dated 12/31/21 showed: -He/she is on Hospice Care. No specific interventions. -No Dementia specific care plan. -He/she is alert with confusion. -Reorient him/her to time and day as needed. -He/she is alert, but cannot remember details. Reorient him/her as needed. 6. During an interview on 3/16/22 at 1:18 P.M. Registered Nurse (RN) B/MDS Coordinator said: -Care plans are updated by him/her and the Director of Nursing (DON) only. -Blood thinners, psychoactive medications and resident specific information should be added to the care plan as they occur. -Charge Nurses notify him/her if there are changes in orders. -Charge Nurses do not update the Care Plan. During an interview on 3/21/22 at 11:11 A.M. Certified Nurse Aide (CNA) C said: -He/she has not received Dementia specific training in the facility. -He/she gets to know the residents and their behaviors. -He/she learns what works for each resident. -He/she does not know of any specific interventions for residents. During an interview on 3/21/22 at 2: 47 P.M. the acting Director of Nursing said: -Any changes or resident specific information is placed on a charting log/report document. -The MDS Coordinator is responsible for checking the log and putting any pertinent information into the care plan. -He/she expects Hospice to keep the care plan updated with their responsibilities. -He/she expects the care plan to define what Hospice and faciltiy staff are responsible for. During an interview on 3/21/22 at 3:47 P.M. CNA D said: -He/she has received no Dementia or Care Plan training from the facility. -He/she learns behaviors on his/her own and tries different things until something works. -He/she is unsure of where specific information about interventions would be. Based on observation, record review and interviews, the facility failed to ensure they developed person-centered, complete, accurate and individualized care plans based on residents' comprehensive care plans to address the specific needs of the residents which affected for five of 12 sampled residents (Residents #1, #4, #13, #22, and #27). The census was 30. The facility did not provide a policy for developing, implementing or updating residents' plans of care. 1. Review of Resident #13's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/24/21, showed: - A Brief Interview for Mental Status (BIMS) score of 6, indicating moderate cognitive impairment; - Scored a 1 on the mood interview, meaning the resident is not at risk for depression; - Independent with bed mobility, moving on the nursing unit, eating; supervision with personal hygiene, toilet use, moving off the nursing unit, and walking in the corridor; limited assistance with dressing; - Diagnoses included only: Dementia without behavior disturbance, Diabetes Mellitus; - Received insulin injections seven of the previous seven days and has orders for insulin; received antipsychotic, antianxiety, antidepressant medications seven days of the previous seven days; received anticoagulant medications seven of the previous seven days. Review of the resident's March 2022 physician's order sheet (POS) showed: - Blood glucose monitoring daily at hour of sleep (HS), order date 7/24/19; - Blood glucose monitoring three times a day before meals, order date 7/24/19; - Basaglar KwikPen (insulin administered via a dosing pen) 13 units, subcutaneous, daily at HS, order date 11/15/21; - Novolin R (insulin regular) 5 units, subcutaneous, three times a day before meals, order date 12/9/21. Review of the resident's care plan, printed on 3/16/22 showed: - Staff did not develop or implement any interventions for the resident's use of insulin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Review of Resident # 27 Quarterly Minimum Date Set (MDS), a federally mandated assessment instrument completed by staff, dated 2/18/22 showed: -BIMS of 1, unable to make decisions -Diagnosis of Dementia with behavioral disturbance and Diabetes -Resident needs extensive assistance to total dependence with Activities of Daily Living (ADLs) -Activity preferences include: music, animals/pets, books, magazines and going outside. Review of Resident's Care Plan dated 11/26/21 showed: -He/she is alert with confusion. -He/she won't remember when activities begin -Invite me to activities and assist with getting him/her there. Review of resident medical record showed: -No documented activity participation between January 1, 2022 and March 21, 2022. Observations during the time of 3/14/22 to 3/21/22 showed: -Resident in room watching television at times -1:1 activities did not occur -Resident was not assisted to the Bingo activity on 3/15/22 2. Review of Resident # 4 comprehensive MDS dated [DATE] showed: -BIMS of 0 (indicates morbid cognitive loss) -Diagnosis of Sepsis (potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues), Urinary Tract Infection and Dementia. -He/she needs extensive assist to total dependence for ADLS. -Activity preferences include: animals/pets and going outside. Review of Resident's Care Plan dated 12/3/21 showed: -Simplify tasks to promote his/her involvement. -He/she is alert with confusion. -No care plan for activity preference. -Remind him/her of times and locations of activities. Review of resident medical record showed: -No documented activity participation January 1, 2022 through March 21, 2021 Observations during the time of 3/14/22 to 3/21/22 showed: -Resident in his/her room visiting with family in the morning -1:1 activities did not occur -Resident was not assisted to the Bingo activity on 3/15/22 3. Review of Resident #22 Quarterly MDS dated [DATE] showed: -BIMS of 3 (indicates severe cognitive loss) -Diagnosis of Congestive Heart Failure, Dementia and Neurogenic Bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems) -Needs extensive assistance to total dependence on staff for ADLs. -Activity preferences include: books, magazines, and religious activities. -Receives Hospice Care Review of Resident's Care Plan dated 12/31/21 showed: -He/she is on Hospice Care. -He/she is alert with confusion, reorient as needed. Review of resident medical record showed: -No documented activity participation between January 1, 2022 and March 21, 2022. Observations during the time of 3/14/22 to 3/21/22 showed: -Resident in his/her room with television on. -1:1 activities did not occur -Resident was not assisted to the Bingo activity on 3/15/22 4. During an interview on 3/16/22 at 3:29 P.M. the Administrator said: -The previous Activities Director retired December 31, 2021 -A new staff member is to start March 21st,. -Activities have been a joint effort of Social Services, Business Office Manager and Certified Nurse Aide (CNA) students from the Area Technical School -He/she would expect activities to be charted in the medical record as resident attends. During an interview on 3/17/22 at 11:42 A.M. Certified Medication Technician (CMT) A said: -Audio books, and music are often turned on for Residents #22 and #27. -This is not documented in the resident's medical records. During an interview on 03/21/22 at 2:35 P.M. Social Service Director said: -He/she is covering activities as much as possible. -He/she charts what each resident attends. -If nothing is charted then resident did not attend an activity. -1:1 visits are completed. Not all are charted due to some being completed by housekeeping staff. - There is no activity calendar this month. -January and February calendars were done by the previous Activity Director. -The January and February calendars were utilized but no March calendars were made. -New activity staff is to start soon. During an interview on 3/21/22 at 2:47 P.M. Acting Director of Nursing (DON) said: -Hospice will provide activities. - CNA students from tech school provide activities - Residents are taken outside during nice weather. -1:1 visits are completed if appropriate. -Social Service Director has been providing bingo. -Office staff is doing activities. -There is a housekeeping staff member that will provide 1:1 visits. -Activities are expected to be charted in the ADL tracker. Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities designed to meet the resident's interests for three of 12 sampled residents. (Resident #27, #4, #22). The facility census was 30. Review of facility policy for Providing Activities, dated January 2019, showed: -It is the policy of the facility to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests, and the physical, mental and psycho-social well-being of the residents. -The facility identifies each resident's interests and needs and involves the resident in an ongoing program of activities that is designed to appeal to his or her interests, and to enhance the resident's highest practicable level of physical, mental and psycho-social well-being.

Based on observation, record review and interviews, the facility failed to ensure they conducted assessments for risk of entrapment from bed rails prior to installation and failed to review the risks and benefits of bed rails with the resident and their representative and obtain informed consent prior to installation. This had the potential to affected all facility residents, and affected one of 12 sampled residents (Resident #25). The facility census was 30. The facility did not provide a policy on bed rails. 1. Review of Resident #25's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, date 2/4/22, showed: - A Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment; - Independent with bed mobility, transfers; not steady when moving from a seated to standing position or moving from surface to surface, but steady with human assistance; - Diagnoses included unspecified sequelae of cerebral infarction (residual effects or conditions produced after the acute phase of an illness or injury has ended) and depression; - Two falls in the assessment period; - Antidepressant use seven out of seven days. Review of the resident's care plan, printed on 3/16/22, showed: - I am at risk for falls due to impaired balanced related to my stroke, implemented 11/21/21; - Please provide one assist with all transfer and ambulating using a gait belt and walker when I feel weak or off balance. - Please remind me to always call for assistance when I get out of bed, especially at night and after waking up in the morning or from a nap. - Remind me to call for assistance when my knees are hurting to prevent falls. - Ensure my pathways are clear, especially by my bed. - Conduct hourly room checks to assist for safety. - I have been sitting on the very edge of my bed; when you observe this, please encourage and assist me with repositioning. - Monitor for safety awareness when using my walker, I sometimes look around and am at risk for losing my balance. - The care plan did not address the use of cane or quarter bed rails on the resident's bed. Review of the resident's electronic medical record (EMR) showed no bed rail assessment, no consent or education provided to the resident or his/her responsible party, no entrapment risk assessment. Review of the post fall evaluation, dated 12/21/22, showed: - Date and time of fall: 12/21/21 at 6:30 P.M.; unwitnessed; - Found in floor in resident room; - Interventions in place at the time of the fall: consult with family, gait belt used when assistance provided, night light use in bathroom/hallway, walker at bedside. Review of the post fall evaluation, dated 12/30/21, showed: - Date and time of fall: 12/30/21 at 6:55 A.M.; unwitnessed; - Location of fall: resident room; - Description of the fall activity: foot wear not non-slip, from regular bed; - Bed in low position, call device within reach, personal items within reach, traffic path in room free of clutter; - Team meeting notes: staff had awaken resident earlier to get ready for breakfast. Staff heard cry out from another room with observing resident sitting on floor beside bed and in front of dresser drawers beside bed and rocker. Resident sock footed and states I fell off the bed, because of these slick floors. Resident with active range of motion to all extremities. Resident assisted off floor with gait belt and two-assist after putting on underwear. Review of post fall evaluation, dated 1/28/22, showed: - Date and time of fall: 1/28/22 at 7:40 A.M.; unwitnessed; - Location of fall: resident room, found in floor; - Adequate room lighting, call device within reach, personal items within reach, traffic path in room free of clutter; - Resident observed on floor beside bed. 2 centimeters (cm) by 2 cm skin tear noted to right forearm and 1 cm by 1 cm skin tear noted to top of right hand. Hematoma noted to right side of head. Resident unable to say how he/she fell. Skin tears cleansed and steristrips applied. Covered with bandage. No other injuries noted. No complains of pain or discomfort. Assisted to chair with two person staff assist with gait belt. Observation on all days of the survey, 3/15/22 through 3/17/22 and 3/21/22, showed the resident had quarter bed rails on his/her bed that were always in the upright position. During an interview on 3/21/22 at 11:00 A.M., the Clinical Nurse said staff should be doing bed rail assessments and the entrapment risk assessments. The assessments are in the EMR and should be done. If staff have done them, they would be in the EMR under evaluations and forms. If they are not there, it was not done. She believes the maintenance director completes the entrapment risk assessments. She thought they were in a binder in the Director of Nursing's (DON) office but could not find them. Most beds in the facility have the cane rails or quarter rails on the beds, but they did not use half or full rails. These rails should be treated the same as half or full rails. During an interview 3/21/22 at 2:01 P.M., the Maintenance Director said he does not do the bed rail assessments for entrapment risk. He had done them at a previous job, but had not been asked to do them here. During an interview on 3/21/22 at 2:50 P.M., the acting DON said side rail assessments should be done annually with the MDS. They should be done in the EMR. If they are not there, they have not been done. They are not doing the entrapment assessments that she is aware of.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Record review of Resident #14's admission Face Sheet showed he/she was admitted to the facility on [DATE] with the diagnosis of Dementia with behavioral disturbances. Record review of the resident's significant change Minimum Data Set (MDS) a federally mandated assessment instrument completed by the facility staff for care planning dated 12/31/21 showed : -His/her BIMS (brief interview for mental status) score of 0 ( indicating morbid cognitive impairment) -Had an active diagnosis of Dementia; -He/she exhibited no behaviors; -He/she needed extensive assistance to dependence with Activities of Daily Living. (ADLs) Record review of the resident's Comprehensive Care Plan showed the resident did not have a care plan related to the diagnosis of Dementia and any related care that was to be provided. 2. Record review of Resident #27's admission Face Sheet showed he/she was admitted to the facility on [DATE] with the diagnosis of Dementia with behavioral disturbances. Record review of the resident's Quarterly MDS dated [DATE] showed : -A BIMS score of 1 indicating he/she was morbidly cognitively impaired. -Had an active diagnosis of Dementia; -He/she exhibited no behaviors. -He/she required extensive assistance to dependence on staff for ADLs. Record review of the resident's Comprehensive Care Plan showed the resident did not have a care plan related to the diagnosis of Dementia and any related care that was to be provided. 3. Record review of Resident #4's admission Face Sheet showed he/she was admitted to the facility on [DATE] with the diagnosis of Dementia. Record review of the resident's Significant change MDS dated [DATE] showed : -A BIMS score of 2 indicating he/she was morbidly cognitively impaired. -Had an active diagnosis of Dementia; -He/she exhibited no behaviors. -He/she required supervision to extensive assistance of staff for ADLs. Record review of the resident's Comprehensive Care Plan showed the resident did not have a care plan related to the diagnosis of Dementia and any related care that was to be provided. 4. Record review of Resident #22's admission Face Sheet showed he/she was admitted to the facility on [DATE] with the diagnosis of Dementia. Record review of the resident's Quarterly MDS dated [DATE] showed : -A BIMS score of 3 indicating he/she has severe cognitive impairment. -Had an active diagnosis of Dementia; -He/she exhibited no behaviors. -He/she required extensive assistance to dependence on staff for ADLs. Record review of the resident's Comprehensive Care Plan showed the resident did not have a care plan related to the diagnosis of Dementia and any related care that was to be provided. During an interview on 3/16/22 at 1:18 P.M. RN B/MDS Coordinator said: -Care plans are updated by him/her and DON only. -Blood thinners, psychoactive medications and resident specific information should be added to the care plan as they occur. -Charge Nurses notify him/her if there are changes in orders. -He/she is currently working 3 night shifts a week and completes Care Plans and MDS as he/she has time. -Charge Nurses do not update the Care Plan. During an interview on 3/21/22 at 11:11 A.M. CNA AC said: -He/she has not received Dementia specific training in the facility. -He/she gets to know the residents and their behaviors. -He/she learns what works for each resident. -He/she does not know of any specific interventions for residents. During an interview on 3/21/22 at 2: 47 P.M. the acting Director of Nursing said: -Any changes or resident specific information is placed on a charting log/report document. -The MDS Coordinator is responsible for checking the log and putting any pertinent information into the care plan. -He/she expects Hospice to keep the care plan updated with their responsibilities. -He/she expects the care plan to define what Hospice and faciltiy staff are responsible for. Based on interview and record review, the facility failed to ensure that a dementia care plan was developed for four sampled residents (Residents #14, #4, #22, and #27) with dementia diagnosis out of 12 sampled residents. The facility census was 30. The facility did not provide a policy to address behaviors or handling residents with dementia.

Based on record review and interviews, the facility failed to ensure they used the services of a registered nurse (RN) for at least eight consecutive hours a day on the day shift, seven days a week. This had the potential to affect all residents who resided in the facility. The facility's census was 30. Review of the facility's undated policy regarding RN coverage showed the requirements for long term care facilities require that a skilled nursing facility provide 24-hour nursing services, an RN for eight consecutive hours a day, seven days a week (more than 40 hours a week), and that there be an RN designated as Director of Nursing (DON) on a full time basis. Review of the facility's December 2021 schedule sheets, which showed all nursing staff scheduled for the entire month of December, showed: - 12/8/21, 12/9/21, 12/21/21, 12/22/21, and 12/28/21 they only had an RN scheduled 4 hours during the day, from 2:00 P.M. to 6:00 P.M.; - On 12/15/21, they only had an RN scheduled 3 hours during the day, 3:00 P.M. to 6:00 P.M.; - On 12/14/21, and 12/27/21 the facility did not have an RN scheduled at all during the entire day. Review of the facility's January 2022 schedule sheet showed: - On 1/2/22 the facility had an RN scheduled for 3 hours, from 3:00 P.M. to 6:00 P.M.; - On 1/4/22, 1/5/22, 1/10/22, 1/11/22, 1/12/22, 1/24/22, and 1/30/22 the facility had an RN working on the evening shift, from 6:00 P.M. to 6:00 A.M.; - On 1/19/22 and 1/25/22, the facility did not have an RN scheduled at any time during these days; on 1/19/22, the schedule did not show they had a nurse scheduled at all during the evening shift; - On 1/26/22, the facility only had an RN scheduled for 4 hours, from 2:00 P.M. to 6:00 P.M. Review of the February 2022 schedule sheet showed: - On 2/1/22, the facility had no RN coverage for the day; - On 2/2/22 and 2/7/22, the facility had an RN scheduled for only four hours, from 2:00 P.M. to 6:00 P.M.; - On 2/9/22 and 2/27/22, the facility had an RN scheduled for 3 hours, from 3:00 P.M. to 6:00 P.M., then had another RN scheduled for a 12 hour shift from 6:00 P.M. to 6:00 A.M.; - On 2/16/22 and 2/22/22, the facility had an RN scheduled for the evening/night shift only, from 6:00 P.M. to 6:00 A.M.; - On 2/23/22, the facility had two RNs scheduled to work 3 hour shifts, from 3:00 P.M. to 6:00 P.M. but no other RNs scheduled. Review of the March 2022 scheduled sheet, from 3/1/22 to 3/21/22, showed: - On 3/1/22, 3/7/22, 3/12/22, and 3/13/22, the facility had an RN scheduled for the evening/night shift only, from 6:00 P.M. to 6:00 A.M.; - On 3/2/22, 3/8/22, 3/9/22, 3/15/22, 3/16/22 and 3/21/22, the facility did not have any RNs scheduled to work. Observation on 3/16/22 at 11:02 A.M. of the staffing sheet hanging on the wall outside the business office showed no RN coverage for today. During an interview on 3/16/22 at 1:15 P.M., the Administrator said she works on the schedules and tries to ensure they have RN coverage. They cannot get agency staff to come. They will have them scheduled and approved then they will not show up when they are scheduled. They have put ads in local papers, and online with no responses. During an interview on 3/21/22 at 2:50 P.M., the acting Director of Nursing (DON) said she and the administrator work in tandem on staffing. The Administrator keeps track of the RN coverage. During an interview on 3/21/22 at 4:19 P.M., the Administrator said she tries to get all shifts covered to ensure RN coverage. They may have a day that they do not have one, given when the acting DON and RN B work. She has tried to always have one, but it just is not always possible.

Based on observation, record review and interviews, the facility failed to ensure they provided each resident with a nourishing, palatable, well-balanced diet to meet their daily nutritional and special dietary needs when staff failed to ensure they covered foods when transporting them from the kitchen to resident rooms and prepared the meals too far in advance. This affected all residents who received their meals from the facility's kitchen. The facility census was 30. The facility did not provide any dietary policies regarding covering foods during transport of when to prepare the meals. 1. Observation and interview on 3/16/22 at 10:26 A.M., the dietary manager (DM) said she already had to noon meal prepared and on the steam table. The evening cook would be starting his/her meal prepare around 3:00 P.M. Observation of the noon meal on 3/16/22 showed staff served the residents' choice meal for the noon meal, chili and a baked potatoes. The bake potatoes appeared to have shriveled from sitting on the steam table for too long. Observation and interview on 3/16/22 at 3:20 P.M. showed the evening meal already on the steam table. [NAME] A said he/she had already completed all of the evening meal preparation. He/she said he/she will make the mechanical soft foods about 5:00 P.M., so it is the last thing he/she does before it is served. Observation and interview on 3/16/22 at 4:58 P.M., the kitchen cleaned and dietary staff ready to service the evening meal. [NAME] A said he/she had already completed the preparation of the ground meats. Observation of the evening meal showed the creamy mushroom chicken appeared to have dried out some from sitting on the steam table for so long and the green beans appeared to be soggy. During an interview on 3/16/22, at 5:00 P.M., the DM said it is not customary to have meals prepared so far in advance. Foods should not sit on the steam table for hours prior to the meal service. 2. Observation on 3/21/22 at 11:30 A.M., showed [NAME] B served meal trays to residents in the dining room. Once all residents in the dining room were served, dietary staff began filling trays to take to the residents who received room trays. Staff covered the hot plate, with the entree and vegetable. Staff picked up small plates of brownies and put them on the trays uncovered. Staff did not cover the brownie plates before taking them down the halls to the residents who ate in their rooms. During an interview on 3/21/22 at 2:45 P.M., the DM said staff should cover plates, drinks as well as side dishes and desserts with plastic wrap prior to placing them on the cart to go to hall with the residents' names.

Based on observation, record review and interviews, the facility failed to ensure they stored, prepared, and distributed foods in accordance with professional standards of food service safety when staff did not date foods when opened, did not change gloves and wash their hands when moving from one task to another, and failed to keep all surfaces clean, all of which affected all residents who received food from the facility's kitchen. The census was 30. The facility did not provide any cleaning schedules. The facility did not provide a policy on hand washing and glove changes in the kitchen. The facility did not provide a policy to address dating foods when opened. 1. Observation on 3/14/22 at 10:20 A.M., during the initial tour of the kitchen showed: - The walking refrigerator: black cherry drink not dated, opened, two individual condiment cups not dated, ham slices in zip lock bag not dated and on top of defrosting vegetable soup; - The ultra skillet handles were greasy and sticky with thick black substance; - The controls on oven with thick black greasy residue; - The smoke detectors dirty and dusty; - In the ice maker, a black and pink slimy mold-like substance on seal and white plastic flap; - The ceiling brackets which held the ceiling tiles in place above the food preparation area were rusted; - The walls of the kitchen had greasy residue. During an Interview and record review on 3/14/22 at 10:20 A.M., the dietary manager (DM) said staff do deep cleaning weekly. Staff are to initial the list when completed. Review of the cleaning list showed no staff signatures for last week. 2. Observation on 3/14/22 at 4:03 P.M., showed the coffee and water machine in the dining room, with dry crusty brown material behind water spout. The Ecolab light cover in dining room was covered with dirty. Observation on 3/16/22 at 10:45 A.M., of the refrigerator in the main dining room showed: - An open container of cheese sticks labeled with a resident's name but no date of when it was opened; - Bottles of coffee creamer not dated, and labeled only with a staff member's first name; - Two bottles of salad dressing, labeled with the same staff member's name and not dated; - A small plastic bowl of what appeared to be spaghetti without a date, label of who it belonged to; - A bowl inside a Ziploc baggies with four pieces of cake and K.H. written on it and no date; - Inside the freezer was an uneaten milkshake without a name or a date on it; and a rubber glove with what appeared to be hashbrowns inside it. During an interview on 3/16/22 at 10:45 A.M., the DM said staff should not put items in the refrigerator, it is for resident use only. Observation on 3/16/22 at 10:26 A.M., showed: - The brackets holding the ceiling tiles in place rusted and pulled away from the tiles; - The ceiling tile above the freezer door with two water spots and a black mold-like substance; - 29 bottles/containers of various spices opened with no dates of when they were opened; - [NAME] cabinet faces were all dirty and sticky to touch; - In the store room, two bags of beans sat on the floor beside the bread cart; - The flour and sugar containers were dirty with a film on them; a white powdery substance could be seen on the floor around the containers; - An open Pepsi can sitting on a shelf in the dishwashing area. During an interview on 3/21/22 at 2:45 P.M., the DM said: - Spices should be labeled after opening and thrown away after six months. Kitchen staff have not been doing this. She knows they have spices that are not labeled; - She has a cleaning scheduled made for each shift, each day as to what needs to be cleaned and staff are to sign off on the lists daily. Schedules are made daily. 3. Observation on 3/21/22 at 11:29 A.M., showed [NAME] B did the following: - Wearing gloves, touched lid to the plate warms, used the same gloved hand to go into different drawers looking for utensils; - Continued to serve meal trays for residents, touch plates with the same gloved hands; - Went into the freezer to retrieve frozen fish and put fish in the fryer wearing the same gloves; - Ran out of ground meats so he/she used a scoop to add meat to a plate, used the clean mixer and used his/her gloved hand to scrap the meet into the mixer; he/she did not change his/her gloves or wash his/her hands. - Wearing the same gloves he/she continued serving hall trays; - Got a pan and sprayed the pan, took fish from the fryer to temp then went to serve another hall tray; - [NAME] B walked away from the serving area and prior to coming back, he/she removed his/her gloves, washed his/he hands and threw the paper towels away touching the lid with his/her clean hands; He/she applied new gloves and went back to serving meal trays. During an interview on 3/21/22 at 2:45 P.M., the DM said staff should change their gloves and wash their hands when changing out food on the steam table, when changing food preparation and whenever they leave their station. Basically, when going from one task to another.

Based on interview and record review the facility failed to follow their set Antibiotic Stewardship Program (ASP) when they failed to maintain appropriate antibiotic tracking and use of the standard assessment and communication tool-SBAR for 3 residents (Resident #22, #24 and #27) out of 17 sampled residents. This had the potential to effect all residents. Facility census was 30. Review of facility policy Antibiotic Stewardship Program dated September 2017 showed in part: -The facility will use a standard assessment and communication tool for residents suspected of having an infection-SBAR. -Monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of changes. -The Infection Preventionist will be responsible for the ASP in the faciltiy i.e.: -Tracks antibiotic starts, resistance patterns, and/or increased usage rates. -Tracks the number of adverse events. - Monitor SBAR forms for completion 1. Record review of Resident #22 medical records showed: -Order for Macrobid (a prescription medication used to treat urinary tract infections) 100 milligrams (mg) by mouth, twice a day, for Urinary Tract Infection (UTI) on 2/15/22. -The Electronic Health Record (EHR) Infection Control Long Term Care (SBAR) form was not completed. Stated no qualifying data. 2. Record review of Resident #27 medical records showed: -Order for Doxycycline (a prescription medication used to treat infections) 100 mg by mouth twice a day for 10 days for UTI on 1/27/22. -The Electronic Health Record (EHR) Infection Control Long Term Care (SBAR) form was not completed, with no qualifying data. -Order for Keflex (a prescription medication used to treat infections) 500 mg by mouth, three times a day, for UTI on 2/22/22. -The Electronic Health Record (EHR) Infection Control Long Term Care (SBAR) form was not completed. 3. Record review of Resident # 24 medical records showed: -Order for Bactrim DS (define) by mouth twice a day for 2 days for UTI on 2/26/22, after hospitalization. -The Electronic Health Record (EHR) Infection Control Long Term Care (SBAR) form was not completed, with no qualifying data. Review of facility infection control tracking showed no tracking of antibiotic usage for March of 2022. During an interview on 3/16/22 at 1:18 P.M. Registered Nurse (RN) B/Infection Preventionist said: -He/she is currently working as Charge Nurse three nights a week. -He/she is not able to keep the infection control information done. -He/she is notified of new antibiotic orders during report from Nurse to Nurse. During an interview on 3/17/22 at 1:46 P.M. the acting Director of Nursing said: -The EHR infection control task will auto populate to be completed when an antibiotic is ordered. - The task only populates when an antibiotic is started. - The task is left open until the antibiotic is finished then has to be closed out. -He/she usually closes it out. -There are some that need closed. -Any new antibiotic , falls, observation etc is placed on the charting log and given to the Infection Prevnetionist at the end of the month for infections to be tracked. -There is a book with the tracking logs. -He/she is unsure why there is not one for March. During an interview on 3/21/22 at 10:39 A.M. the Administrator said: - Nursing is responsible for completing infection control tasks in the EHR. -The Infection Preventionist or Acting DON would be ultimately responsible. -He/she would expect the SBAR/infection control task to be completed in a timely manner.

Based on observation, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included objectives and timeframes to meet medical and nursing needs for one of 12 sampled residents (Residents #29). The facility census was 30. Review of the facility's policy for Use of the RAI (Resident Assessment Instrument) Process, dated November 2017, showed: - Staff utilized the RAI process to assist in gathering information on a resident's strengths and needs, which must be addressed in the individualized care plan; - The RAI assisted staff with evaluating goal achievement and revising care plans and allows for an interdisciplinary approach to foster a more holistic approach to resident care that assesses residents' needs, strengths, goals, life history and preferences; - The plan of care is based on the assessment and identification of resident problems, reflects the strengths and areas of improvement for residents admitted to the facility. - The full plan of care is developed during an interdisciplinary care plan team meeting. - The facility must develop and implement a comprehensive person-centered care plan for each resident; - The plan includes resident personal preferences as well as services and interventions that are designed to help the resident achieve goals for care, address reason for admission. 1. Review of Resident #29's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/1/19, showed: - A Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairment; - Extensive assistance from staff for bed mobility, transfers, moving on and off the nursing unit, dressing, toilet use and personal hygiene; - Diagnoses included: anemia, high blood pressure, urinary tract infection in the past 30 days, diabetes, stroke, anxiety, depression and dementia; - On a scheduled pain management regimen; - At risk for pressure ulcers; - No diabetic foot ulcers; did not indicate any applications of a dressing to the feet. Review of a communication with the resident's primary care physician (PCP), dated 12/13/18, showed: - Staff asked for an order for the contracted wound team to evaluate and treat a wound on the resident's left foot; - PCP responded on 12/14/18, giving permission for the resident to be followed by the wound team. Review of the wound care team notes showed: - 12/27/18: left heel diabetic ulcer; measures 0.5 centimeters (cm) by (x) 0.5 cm with no measurable depth, with an area of 0.25 square (sq) cm; no tunneling noted; no undermining noted; no drainage noted; wound pain = 4/10; wound bed has 76-100% eschar (dead tissue), no granulation, no slough; wound is improving; treatment included cleans with hypochlorous acid, paint skin with Skin Prep over area of stable eschar; change daily; - 1/3/19: documented no changes to the wound, 0/10 pain level and no changes to the treatment; - 1/10/19: 0.4cm x 0.4cm with 0.16 sq cm area, no other changes noted; no changes to treatment; - 1/17/19: 0.3cm x 0.3cm with 0.09 sq cm area, no changes noted; no treatment changes; - 1/31/19: 1.8cm x 1.9cm with a 3.42 sq cm area, no other changes noted; no changes to treatment; - No documentation for 2/7/19; - 2/14/19: no measurements, only listed the treatments and listed no changes; - 2/21/19: same as 2/14/19; - 2/28/19: 1cm x 2cm, with a sq cm area of 2 cm, no other changes to the wound or the treatment; - 3/7/19: No measurements of the wound; changed dressing to add calcium alginate- Santyl (used to remove dead skin and tissue) nickel thick to entire wound bed; cover with bordered gauze daily. Observations of the resident at various times throughout the days of 3/11/19 through 3/14/19, showed the resident sat in his/her wheelchair wearing non-skid socks on his/her feet. The resident's heels rested on the footrest of the wheelchair. Review of the resident's care plan, printed on 3/13/19, showed: - Under Activities of Daily Living (ADLs): Inspect my skin during baths ad care; notify charge nurse of any issues; - Pain: No interventions listed; - Skin: No interventions listed. Observation on 3/14/19, at 11:37 A.M., showed the wound care team measuring the resident's wound and Licensed Practical Nurse (LPN) A changed the dressing to the wound. The wound was located on what appeared to be the bottom of the resident's foot, at the back of his/her heel. Staff had to get on hands and knees and use a camera on a tablet to see the wound. Review of the wound care team notes, dated 3/14/19, showed: - Measured 1cm x 2.6cm x 0.1 cm depth; with an area of 2.6 sq cm and a volume of 0.23 cubic cm; - Undermining noted at 3:00 and ends are 6:00 with a maximum distance of 0.2cm; - Moderate amount of drainage with no odor; - Pain level of 8/10; - Wound bed has 26-50% slough (dead tissue), 26-50% pink granulation (new skin); - No change noted to wound progression; - No change to treatment. During an interview on 3/13/19, at 1:33 P.M., the corporate nurse said the dates that are missing was when the weather was bad and the wound team could not make it. She cannot find where facility staff charted the wound measurements. During an interview on 3/14/19, at 9:40 A.M. the MDS coordinator said the resident had area to his/her heel that was present last August but it healed after putting skin prep on it. It was caused by bumping it. The resident went out with family over Thanksgiving and bumped it again. It is on the side of her heel, not the bottom of it. The dates when the wound was not measured by the wound care team were dates when there was a lot of snow and they could not get to the facility. No one measured the wound in the facility on those days. During an interview on 3/14/19, at 12:07 P.M. the Director of Nursing (DON) and MDS Coordinator said they were responsible for updating the care plans. They listen in report to find out any changes to the residents. If a fall, will add right then. It depends on what it is if they added it to care plan. They just missed Resident #29's heel wound, and does see that should have added more interventions. They have been working to get the care plans cleaned up as they do the MDS.

Based on observations, interviews, and record reviews, the facility failed to ensure staff washed and changed on a daily basis compression stockings for one of 12 sampled residents (Resident #17). The facility census was 30. 1. Review of Resident #17's undated care plan showed did not discuss the use of compression stockings. 2. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/1/19, showed: - Cognitively intact; - Required staff supervision for dressing; - Used a wheelchair and walker for ambulation; - Diagnoses included depression and lung disease; - Shortness of breath with exertion and lying down; - Received diuretics, antidepressant and antianxiety medications; - Received oxygen therapy. Observation on 3/11/19 at 1:41 P.M. and 3/13/19 at 11:25 A.M. of the resident showed the resident in bed wearing compression stockings, on both legs from his/her ankles to his knees. During an interview on 3/11/19 at 1:41 P.M. the resident said: - Staff did not change and wash his/her compression stockings on a daily basis. - Staff only changed his/her compression stockings when he received a shower. During an interview on 3/13/19 at 11:25 A.M. Certified Nurse Assistant (CNA) A said; - He/she did not check the resident's compression stockings on a daily basis. - He/she thought the compression stockings should just cover the resident's ankle to knees. - He/she only changed and washed the resident's compression stockings when he took a shower. During an interview on 3/13/19 at 11:25 A.M. Licensed Practical Nurse (LPN) A said: - Compression stockings should cover the resident's feet to under the knees. - Staff should wash and change the resident's compression stockings daily. During an interview on 3/13/19 at 11:25 A.M. the Director of Nursing (DON) said: - Compression stockings should always cover a resident's feet and ankles up to the knees. - Staff should place the compression stockings on the resident in the morning an remove them every night. - Staff should wash the compression stockings daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident 3's quarterly MDS dated [DATE] showed: -No cognitive impairment. -Diagnoses included: dementia, anxiety disorder, and major depressive disorder. -Antipsychotic medications received on routine basis. Review of the resident's current POS showed: -An order for PRN Alprazolam 0.5 mg, a controlled psychotropic medication used to treat anxiety, with a start date of 3/8/19. Review of the resident's medical record showed: -No fourteen day stop date or documentation of rationale to extend the use of the PRN psychotropic medication from the physician. 5. Review of Resident #4's quarterly MDS dated [DATE] showed: - Brief Interview for Mental Status score of 00 which indicated the resident was unable to complete the assessment due to severe impairment. -Diagnoses included: dementia, anxiety disorder, and depression. Review of the resident's current POS showed: -An order for PRN Lorazepam 25 mg, a controlled psychotropic medication used to treat anxiety, with a start date of 2/8/19. Review of the resident's medical record showed: -No fourteen day stop date or documentation of rationale to extend the use of the PRN psychotropic medication from the physician. 6. During an interview on 3/13/19 at 1:00 P.M. the Director of Nursing (DON) said the PharmD should review all prn psychoactive medications and make recommendations after 14 days. Based on interviews and record reviews the facility failed to ensure staff reviewed orders for an as needed (PRN) medication for anxiety after 14 days which affected four of 12 sampled residents (Residents #3, #4, #17 and #21). The facility census was 30. 1. Review of the facility policy, dated January 2019, for GDR's showed each resident should receive a monthly review of their medications by the facility consultant pharmacist (PharmD). 2. Review of Resident #17's undated care plan showed: - The resident received medications for depression and anxiety. - Staff should observe the resident for adverse affects of his/her medications. - Staff should note and report any increased signs of anxiety. Review of the resident's PharmD's recommendations showed: - No reviews between July 2018 through October 1, 2018. - Review of the recommendation dated 10/24/18 showed alprazolam (no dose given) prn, no recommendations. - Review of the recommendation dated 11/27/18 showed alprazolam 0.5 mg used just one time FYI Attn: MD. - Review of the recommendation dated 12/12/18 showed from hospital with diagnosis soft tissue infection and heart failure. - Review of the recommendation dated 1/29/19 showed alprazolam prn used two out of six days, no MD resp. req. - Review of the recommendation dated 2/25/19 showed alprazolam 0.5 mg used 80% of the time no recommendations mentioned. Review of the resident's physician order sheet (POS), dated March 2019, showed an order for alprazolam 0.5 milligrams (mg) to be given three times a day prn for anxiety. Review of the facility Psychotropic medication utilization by resident sheet , dated 12/27/18 through 1/30/19) showed: - The resident had an order, dated 8/3/18, for alprazolam to be used to treat anxiety) 0.5 mg to be given three times a day prn. - The PharmD stated the last GDR was ?. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff,, dated 2/1/19, showed: - Cognitively intact; - Diagnosis of depression; - Received antianxieety and antidepressant medications. 3. Review of Resident #21's significant change in status MDS, dated [DATE], showed: - A BIMS score of 13, which indicated no cognitive impairment; - No indications of depression and no behaviors; - Independent with all ADLs (activities of daily living); - Diagnoses of dementia, depression and did not list anxiety as a diagnosis; - Received an anti-depressant medication seven out of seven days prior to the MDS; - Did not take an anti-anxiety medication during the review period. Review of the March, 2019, POS showed: - Order date 2/1/19: Lorazepam 0.5 mg, every six hours PRN anxiety; - Diagnoses included: dementia without behaviors, major depressive disorder, cancer, but did not include anxiety; - Hospice, order date of 2/1/19. Review of the MAR, dated 2/14/19 through 3/14/19, showed staff did not administer the lorazepam at all during this period. Review of the Pharmacist's Medication Regimen Review, dated 2/26/19, showed: - Lorazepam PRN 0.5 mg every six hours 2/1/19; totally inactive; - No MD (physician) response required; - Did not indicate the resident's PRN order did not have a rationale for extended use or a duration of use.

Based on observations interviews, and record reviews the facility failed to ensure staff discarded expired medications from the e-kit, properly counted controlled substances (substances that could cause physical and/or psychological dependence) which affected two additional residents (Residents #2 and #131, and failed to label when opened and discarded when expired medications which affected one of 23 sampled residents (Resident #29) and one additional resident (Resident #132). The facility census was 30. 1. Review of the package insert, dated November 2013, for tuberculosis (TB) tasting medication showed the medication should be discarded within 30 days of opening. Review of the facility policy, dated 3/10/15, on insulin storage showed: - Staff must date all multi-dose insulin upon opening. - Staff must discard all multi-dose vials of insulin 28 days after opening. Review of the facility policy, dated 3/10/15 on controlled substances showed the consultant pharmacist (PharmD) and the Director of Nursing (DON) will review the e-kit on a monthly basis,\. Review of the facility policy, dated February 2016, on controlled substances, showed: - Staff must count controlled medications on delivery. - Any discrepancies in the controlled substance should be immediately reported to the DON. Observation on 3/11/19 at 1:55 P.M. of Registered Nurse (RN) A and Certified Medication Technician (CMT) A inspecting medications showed: - Resident #131's hydrocodone (a controlled substance)/ chlorphenimane syrup showed should have 125 milliliters (ml) but contained 100 ml; - Resident #2's Tramadol, a controlled substance used for pain, bubble pack with bubble #4 torn and taped with a pill inside the bubble; - Resident #2's hydrocodone, a controlled substance used to relieve pain, 5 milligrams (mg) 325 mg acetaminophen bubble #1 torn and taped with a pill inside the bubble; - In the e-kit one bottle of lorazepam, a controlled substance used to treat anxiety, 2 mg/milliliter (ml) with an expiration date of 1/16/19; - In the e-kit four vials of lorazepam injectable 2 mg/ml with an expiration dated of February 2019; - An opened vial dated 2/5/19 of e-kit lantus insulin; - An opened undated vial of TB testing medication; - Resident #132's opened undated lantus insulin pen; - Resident #29's opened undated lemevir insulin pen. During an interview on 3/11/19 at 1:55 P.M. RN A and CMT A said: - They should always discard any controlled substances behind torn bubbles. - They should always label TB testing medication when opened but were not sure when to discard. - The should discard outdated medications. During an interview on 3/11/19 at 2:00 P.M. the DON said: - Staff should not tape any bubbles. - Staff should discard any pills behind torn bubbles. - Staff should discard any expired medications. - Staff should label any insulin preparations when opened and discard 28 days after opening. - Staff should label TB testing medication and discard 30 days after opening. - Staff must report any narcotic discrepancies immediately. - The consultant pharmacist checked the facility's medications for outdates on a monthly basis.

Based on interview and record review the facility failed to ensure staff offered influenza (flu)and pneumonia immunizations to three of 23 sampled residents (Residents #17, #19, and #23). The facility census was 30. 1. Review of the undated facility policy on immunizations showed: - The facility must offer all residents flu and pneumonia immunizations. - Staff must offer each resident pneumonia immunization every five years. - The facility must offer all residents flu vaccines according to the Center for Disease Control schedule flu season, fall and winter. - The facility must provide the resident and/or responsible party education regarding flu and pneumonia immunizations prior to the flu season. - Staff must track and monitor all resident's immunization status. - All new admissions must be screened for immunizations by the charge nurse. Review of resident #17's immunization records showed staff had not offered the resident a flu immunization for the 2018-2019 flu season. Review of Resident #19's immunization record showed: - The resident refused a flu immunization for the 2018-2019 flu season. - The facility did not have a record of the resident being offered a pneumonia immunization. Review of Resident #23's immunization record showed the facility had no record of staff offering the resident a flu immunization for the 2018-2019 flu season or ever offering the resident a pneumonia immunization. During an interview on 3/13/19 at 7:50 A.M. the DON said: - She just started working as the DON in November 2018. - Staff should offer every resident a flu immunization prior to the beginning of the flu season. - Staff should document each resident's immunizations. - Staff should offer each resident a pneumonia immunization upon admission and every five years there after.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure staff cleaned the filters on oxygen (O2) concentrators clean and free of debris. This had the potential to affect the way the concentrators worked for those residents who needed oxygen to breath. The census was 30. Observation on 3/15/19, starting at 11:40 A.M., showed dust, dirt and debris stuck to the filters on the O2 concentrators in the following resident rooms: - room [ROOM NUMBER]; - room [ROOM NUMBER]; - room [ROOM NUMBER]; - room [ROOM NUMBER]. During an interview on 3/15/19, at 12:40 P.M., the maintenance supervisor said he did not clean the filters; he believed nursing did that. During an interview on 3/15/19, at 1:30 P.M., the Director of Nursing (DON) said staff should be cleaning the O2 filters on a monthly basis. She had not looked at them to see if they are clean.